NURSING ASSISTANT TURNOVER IN HOME HEALTH CARE AGENCIES: A SCOPING LITERATURE REVIEW

Abstract Certified nursing assistants (CNAs) who work in Home Health Care (HHC) are part of the continuum of care and aid in reducing the burden to the acute care system. CNAs assist patients with their activities of daily living and provide social engagement. Since CNAs see patients more frequently, they are crucial for referral to the nursing staff in times of crisis. The Affordable Care Act was enacted in 2010 which expanded HHC services and provides consumers with more health care options. There is a projected 25 percent increase in CNAs needed in HHC between 2021 and 2031. Despite the growth in HHC, the sector has high turnover rates of CNAs. It is estimated that 35 to 65 percent of CNAs leave HHC employment annually. This scoping review utilized the Job Demands-Resource (JD-R) and the Social-Ecological (SE) models to identify trends in turnover. The JD-R can be used to understand how the demands of one’s job as well as the engagement in one’s work can affect overall work-related stress, health, and motivation, and is contrasted with available job resources. The SE framework was used to explore levels of influence, and examines how individuals, relationships, communities, and society interact to influence behavior and perceptions. By using both the JD-R and SE models, it is easier to conceptualize the interaction of factors impacting turnover and that many of these factors are unique to CNAs in HHC. The difficult nature of the work, low pay, and low autonomy mean identifying job resources is critical.

Though access to health care is associated with improved chronic health outcomes, data on dementia risk are limited.From the Ecological Model of Aging, limited access to health care facilities may be associated with increased likelihood of developing dementia through poor management of comorbidities.The current study aims to investigate the association between the density of neighborhood health care facilities and incident dementia.Participants were communitydwelling older adults, systematically recruited from Bronx, NY (N=1,461, mean age=78.4;mean follow-ups=4.6years; 68% non-Hispanic White, 26% non-Hispanic Black).Density of health care facilities in each participant's Census Tract was derived from the National Establishment Time-Series data.We used Cox proportional hazards models using age as the time scale and adjusted for sex, race, education, income, and neighborhood deprivation.Incident dementia developed in 10% of the sample.Older adults living in the areas with lower density of health care facilities, compared to those living areas with a higher density of health care facilities, were at increased risk for incident dementia (HR=1.79,95% CI=[1.12,2.87] for lowest vs. highest tertile; HR=1.65, 95% CI=[1.02,2.66] for intermediate vs. highest tertile).Further controlling for cardiovascular and other comorbidities did not change the pattern of results.The current results suggest that unequal distribution of health care facilities across geographic locations may help account for cognitive health disparities among older adults.Future studies will need to identify behavioral and individuallevel mechanisms (e.g., healthcare use, better treatment before disease occurs) in the association between neighborhood health care facilities and dementia.Exposure to stressful neighborhood environments is a well-established risk factor for health deterioration and premature death.However, the underlying biological underpinnings driving these associations are not fully understood.Epigenetics may function as a key molecular pathway to adverse health outcomes among residents of high-stress neighborhoods.This study examines the association of neighborhood stressors (i.e., socioeconomic deprivation, disorder, and low social cohesion) with three epigenetic aging measures (i.e., DunedinPACE and Principal component adjusted (PC) PCPhenoAge and PCGrimAge) based on DNA methylation levels.Further, we identify sub-populations that are particularly vulnerable to the detrimental effects of neighborhood stressors.Data were from the 2016 Health and Retirement Study (HRS) DNA Methylation Sample, merged with neighborhood stressors measured in the HRS 2012/2014 and the 2012-2016 American Community Survey (N=3,201).Multilevel regression models adjusting for confounders showed that perceived high disorder was associated with accelerated DNAm aging for DunedinPACE (β=0.13,95%CI=0.04-0.23).Perceived low cohesion was associated with accelerated DNAm aging for DunedinPACE (β=0.21,95%CI=0.08-0.35)and PCGrimAge (β=0.09,95%CI=0.04-0.14).High deprivation did not have any significant associations.In models of interactions, associations of low cohesion were more pronounced for females in DunedinPACE (β=0.36,95%CI=0.13-0.60)and PCPhenoAge (β=0.21,95%CI=0.07-0.35).No other interaction effects were found for race/ethnicity, living arrangement, and education.Our findings indicate that neighborhood stressors can speed up epigenetic aging, with older females being particularly vulnerable to the effects of low cohesion.This study provides insights into the biological foundations of health disparities rooted in neighborhood environments.Longitudinal changes in HbA1c (ΔHbA1c) are associated with insulin resistance, aging, cognition, and mortality.To identify novel gene variants underlying ΔHbA1c, we conducted linkage-guided sequence analysis on 17p12 (LODs=3.59) in the Long Life Family Study, a study with familial clustering of exceptional longevity in the US and Denmark.Subjects with clinical diagnosis of diabetes or diabetes treatment and undiagnosed diabetes cases whose fasting glucose ≥ 126 mg/ dl or HbA1c ≥ 6.5% were excluded.ΔHbA1c, collected from two exams 7 years apart, was derived using growth curve modeling, adjusting for age, sex, BMI, smoking, field centers and PCs, and was blom-transformed to approximate normality.We identified a significant variant under the linkage peak (ARHGAP44 rs56340929, p=1.77E-06,MAF=6%, accounting for linkage=26.5%).Taking advantage of our currently available RNAseq data, we found a significant association between quantification of ARHGAP44 RNA transcript and adjusted ΔHbA1c using 16 linkage enriched families (n=176, β = -0.24,SE=0.09, p=0.01).We also assessed currently available lipidomics data (188 metabolites, 13 compound classes) and found phosphatidylcholine (p=0.025) and lysophosphatidylcholine (p=0.02) were marginally associated with adjusted ΔHbA1c.ARHGAP44 is reportedly associated with glycemic traits and is mainly expressed in the brain.Further complete omics-data analyses in the LLFS and a replication study using the Framingham Offspring Study are underway.
assist patients with their activities of daily living and provide social engagement.Since CNAs see patients more frequently, they are crucial for referral to the nursing staff in times of crisis.The Affordable Care Act was enacted in 2010 which expanded HHC services and provides consumers with more health care options.There is a projected 25 percent increase in CNAs needed in HHC between 2021 and 2031.Despite the growth in HHC, the sector has high turnover rates of CNAs.It is estimated that 35 to 65 percent of CNAs leave HHC employment annually.This scoping review utilized the Job Demands-Resource (JD-R) and the Social-Ecological (SE) models to identify trends in turnover.The JD-R can be used to understand how the demands of one's job as well as the engagement in one's work can affect overall work-related stress, health, and motivation, and is contrasted with available job resources.The SE framework was used to explore levels of influence, and examines how individuals, relationships, communities, and society interact to influence behavior and perceptions.By using both the JD-R and SE models, it is easier to conceptualize the interaction of factors impacting turnover and that many of these factors are unique to CNAs in HHC.The difficult nature of the work, low pay, and low autonomy mean identifying job resources is critical.

NURSING HOME INVESTMENT IN HEALTH INFORMATION TECHNOLOGY -AN ORGANIZATIONAL SLACK PERSPECTIVE John McHugh, and Gregory Alexander, Columbia University, New York City, New York, United States
Organizational slack refers to excess resources (e.g., financial, social capital, human capital) an organization accumulates to adapt to changing internal and external contexts.Nursing homes operate in a severely resource-constrained environment, and therefore have limited ability to accumulate organizational slack.However, nursing homes that do accumulate slack may be more likely to invest in health information technology (HIT).To test this, we examine associations between organizational slack and HIT maturity.HIT maturity is the level of IT capabilities, extent of use, and integration in resident care, clinical support, and administration.We linked 2018 data from a national nursing home HIT maturity survey (N=525) to nursing home characteristics from LTCfocus.org,CMS data, National Center for Health Statistics, Medicare cost reports, and other county-level statistics.We incorporated Simple Linear Regression, controlling for facility-level sex, race, case-mix, and urban/rural location.Average 3-year operating income for Stage 0 nursing homes was -$4,387 per bed (n=7) compared to $42,768 per bed in Stage 6 nursing homes (n=17).Higher HIT maturity was associated with greater percentages of Medicare patients and shorter distances to the closest hospital.Our regression model also demonstrated significant associations with operating income per bed, chain affiliation, total beds, occupancy percentage, moderately concentrated counties and case-mix adjusted staffing.In this sample, larger, more financially stable organizations (i.e., those with more slack) may be able to invest more in HIT.As HIT maturity has been shown to be associated with improved patient outcomes, disparities may widen in organizations with lower levels of slack.

NURSING STUDENTS' EXPERIENCES REGARDING PHYSICAL RESTRAINTS: AN INTEGRATIVE REVIEW
Juh Hyun Shin 1 , and Eun-Hi Kong 2 , 1. George Washington University,Ashburn,Virginia,United States,2. Gachon University,Incheon,Gyeonggi,Republic of Korea Many harmful effects related to the use of physical restraints have been reported and restraint-free care has been advocated for in many countries.However, the prevalence of physical restraint use is still high in many care settings around the world.There has been no systematic review study focused on nursing students regarding physical restraints.This study aimed to critically review the existing studies targeting nursing students related to physical restraint using an integrative review method.This study was registered in PROSPERO(CRD42023414410).Eleven electronic databases were searched by two authors: CINAHL, PubMed, EMBASE, PsycINFO, ERIC, Education Source, SCOPUS, RISS, DBpia, Cochrane, and KoreaMed from the earliest year to 2023.A total of 19 studies including diverse research designs were selected.For quality appraisal, both the Mixed Methods Appraisal Tool (MMAT) and the Joanna Briggs Institutes (JBI) checklist were employed.Most studies were conducted in acute clinical care settings.Many studies used a cross-sectional study design, convenience sampling method, small number of participants, and weak measurements.There was a lack of experimental studies, mixed methods studies, and financially funded studies.The main outcomes were nursing students' attitude, knowledge, perception, or practice regarding physical restraints.This integrative review provided new knowledge and understanding about nursing students' experiences regarding physical restraints.Future studies must use more robust research design, sample size, and measurements with research funding.This study showed that more research and education targeting nursing students are needed to achieve restraint-free care.

NUTRITIONAL STATUS AS A RISK FACTOR FOR DEPRESSION AMONG OLDER ADULTS RECEIVING COMMUNITY-BASED AGING SERVICES
Mary Goldsworthy, Timothy Boaz, Amber Gum, and Lawrence Schonfeld, University of South Florida, Tampa, Florida, United States Nutritional status is a significant determinant of overall health and well-being among older adults and is linked to adverse mental health outcomes, such as depression.This study examined nutritional status as a risk factor for depression among 4,469 older adults receiving home-and community-based services from agencies overseen by a fivecounty Area Agency on Aging in west central Florida.It was hypothesized that older adults with a higher nutritional score (i.e., increased risk of malnourishment) would be more likely to have elevated depressive symptoms compared to those with lower nutritional risk.The cross-sectional study used secondary data from the AAA, including demographic and social variables, a 20-point nutritional risk score, and the Patient Health Questionnaire-9 (PHQ-9; not depressed = 0-9, depressed = >10) from clients in the AAA planning and service area.In logistic regression, the most significant predictor of depression was the client's nutrition score (OR=

NOVEL GENE VARIANTS ASSOCIATED WITH HBA1C CHANGES OVER TIME AMONG NONDIABETIC SUBJECTS IN THE LONG LIFE FAMILY STUDY
Siyu Wang 1 , Bharat Thyagarajan 2 , Joseph Lee 3 , Joseph Zmuda 4 , Kaare Christensen 5 , Michael Province 6 , and Ping An 1 , 1. Washington University in St. Louis, St.